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2089
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QUESTIONS ABOUT HAIR LOSS
Please answer the following questions and they will be reviewed and answered for you by a hair loss professional.
How long have you had hair loss?
Since that time, how has your hair loss been?
Better
Worse
Same
Which part of your head has hair loss?
All Over
Front / Hairline
Crown
Back / Lower
Are your hairs:
Breaking Off
Coming Out At The Roots
Do you have any history of anemia, low iron or thyroid disorders? Please explain:
Are you a Vegetarian or vegan?
Yes
No
Do you have a rash or flaking in your scalp?
Yes
No
What do you think is the cause of your hair loss? Please include any other information that you believe may be important.
How Should We Get In Touch With You?
Name
First
Last
Phone
Email
CAPTCHA
99053
